Every finding on record at Medpro Health Providers

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 07/02/26. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of the Emergency Preparedness requirements, on 07/02/26. Standard level deficiencies cited. Abbreviations: QA = Quality Assurance Pt. / Pts. = Patient / Patients AM = morning SOC = Start of Care % = percent OASIS = Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report for the last 12 months and staff interviews, the Agency failed to submit 729 of 3675 assessments within 30 days of completion. Findings include: 1. The Error Summary report for 05/01/25 to 05/28/26, was reviewed on 06/29/26. The report documented 729 of 3675 (19.84%) reports were submitted more than 30 days after the assessment was completed. 2. During staff interview with Director of Nursing, Intake Supervisor and QA/Office Manager on 07/02/26 at 11:30 AM, the above findings were confirmed.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: MSW = Medical Social Worker PT = Physical Therapy OT = Occupational Therapy Pt / Pts = Patient / Patients SN = Skilled Nurse SOC = Start of Care

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on the clinical records review, home observation/interview and Staff interview, it was determined the Agency Staff did not conform to the Physician’s orders. This was found in 5 of 17 (Pts. # 5, 6, 10, 15 and 11) clinical records reviewed. Findings include: 1. Patient #5, was admitted to the home health services on 11/14/22. Diagnoses: Other Bursitis of Hip, Right Hip. The clinical record was reviewed on 07/06/23. The Physician orders dated 05/13/22 included orders for the MSW to evaluate. On 07/06/23 at 2:00 PM, during the interview with the Clinical Manager, it was confirmed the MSW evaluation was not conducted. 2. Patient #6, was admitted to the home health services on 04/05/23. Diagnoses: Encounter for Change or Removal of Non-Surgical Wound and Type 2 Diabetes Mellitus with Diabetic Neuropathy Unspecified. The clinical record was reviewed on 07/05/23. The Physician orders dated 06/04/23 included orders for the Aide to ambulate the Patient. During the home visit conducted on 07/06/23, it was observed that the Aide did not ambulate the bedbound patient. On 07/06/23 at 11:00 am, during the home visit interview with the Aide and the Patient, it was confirmed that the Aide does not ambulate the patient. 3. Patient #10, was admitted to the home health services on 01/10/23. Diagnoses: Encounter for Change or Removal of Non-Surgical Wound and Heart Failure Unspecified. The clinical record was reviewed on 07/05/23. The Physician orders dated 05/10/23 included Skilled Nursing orders for daily weight monitoring. The SN visit notes did not include the patient’s weight for the entire certification period. 4. Patient #15, was admitted to the home health services on 10/08/22. Diagnoses: Unspecified Fracture Right Acetabulum and Heart Failure. The clinical record was reviewed on 07/06/23. The Physician orders dated 12/10/22 included orders for the SN: 1 time a week for 9 weeks, the PT 2 times a week for 2 weeks, 1 time a week for 7 weeks and the OT 2 times a week for 1 week and 1 time a week for 4 weeks. The SN did not assess the Patient for the entire certification period. The OT did not assess the Patient for the entire certification period. 5. Patient # 11, was admitted to home health services on 05/29/23. Diagnoses: Encounter or Change or Removal of Surgical Wound and Rectal Abscess. The clinical record was reviewed on 07/06/23. The Plan of Care dated 05/29/23 contain Physicians orders for SN to measure wound every visit. The SN visit notes from week 2 to week 6 did not contain documentation of wound measurements. 6. During interviews with the Clinical Manager and acting Clinical Manager on 07/06/23 between 2:00pm and 3:00pm finding of Agency staff not conforming to Physicians orders were confirmed.